Inspection on 19/09/06 for Kathleen Chambers

This inspection was carried out on 19th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kathleen Chambers 10/09/08

Kathleen Chambers 19/01/06

Kathleen Chambers 04/08/05

Kathleen Chambers 15/03/05

Kathleen Chambers 22/06/04

Similar services:

Fairfields Country Rest Home

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Honeybourne House

Belma

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kathleen Chambers House 97 Berrow Road Burnham On Sea Somerset TA8 2PG Lead Inspector Pippa Greed Key Unannounced Inspection 09:25 19 September 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kathleen Chambers House Address 97 Berrow Road Burnham On Sea Somerset TA8 2PG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01278 782142 01278 782673 Royal National Institute of The Blind Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (10), Sensory impairment (3), Sensory of places Impairment over 65 years of age (40) Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to three persons between the ages of 55 and 65 years of age with a sensory impairment Up to ten persons, over 65 years, may receive personal care. Overall registered beds must not exceed forty. 19th January 2006 Date of last inspection Brief Description of the Service: Kathleen Chambers House is registered with the Commission for Social Care Inspection (CSCI) to provide care for up to 40 people over the age of 65 who have a sensory impairment. The home itself has been purpose built and equipped to meet the needs of people with a sensory impairment. All service users accommodation has en suite bathroom/shower facilities and a small kitchen area. The home is owned by the Royal National Institute of the Blind (RNIB) but currently there is no Manager registered for the home. The Acting Manager is applying to be registered with the Commission for Social Care Inspection. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was conducted on 19th January 2006. Two requirements were made at this inspection. These have been completed. This inspection was unannounced and took place over the course of one day (8.5hrs) on 19th September 2006. It was undertaken by Regulation Inspector Pippa Greed. The inspector spoke to five service users, and six staff. The assistant manager and acting manager supported the inspector throughout the inspection process. The staffing on the morning of the inspection were as follows; one supervisor, three carers, two catering staff, one activity co-ordinator, one receptionist, one maintenance, one gardener, one laundry staff, and three housekeeping staff. Four service users files were selected for case tracking. As part of the inspection process the inspectors used ‘case tracking’ as a means of assessing some of the national minimum standards. This process allowed the inspectors to focus on a small group of people living in the home. All records relating to these people were inspected, along with the rooms they occupied in the home. Four staff files were checked and documents related to the running of the home were examined. A tour of the building took place and the communal areas and some service users’ rooms were viewed. Mrs Margaret Main-Reade is the acting manager and she is supported by Mrs Stephanie Cahill, assistant manager. Surveys were sent out to five service users, four relatives, three medical and health care professionals and two social workers. Five surveys were received from service users. Three comment cards from general practitioners and two comment cards from social workers. All the comments received from service users on the day of the inspection and through anonymous surveys were complimentary about the home in general and included comments such as ‘The carers are always helpful’, ‘They’re marvellous. They’re very patient’, ‘I’ve never regretted it, always been happy here.’ However, three service users commented through anonymous surveys and feedback on the day that the quality of meal served was poor. Medical professionals and Social Worker confirmed that the home was well run. The inspectors would like to thank the service users, staff and management team for their support and assistance with the inspection process. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 6 The current fee levels are £440 per week and also ranges from £487 to £550 per week for a single or double occupancy flat. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 (6 is not applicable) The quality in this outcome group is excellent. The home provides a statement of purpose, and welcome pack that clearly sets out the objectives and philosophy of the service. Prospective service users are given the opportunity to spend time in the home. Admissions are not made to the home until a full needs assessment has been undertaken. Each service user is provided with a clear contract that sets out the terms and conditions of residency. EVIDENCE: The Statement of Purpose has been updated September 2006, which provides information relating to the service provision and structure of the home. Out of five service users surveys, four confirmed that they chose to live at Kathleen Chambers House and were provided information about the home. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 9 Some had the opportunity to ‘test drive’ the home through short stay residency. Service users spoken with confirmed this. The home is able to provide Braille, tape recording or large print ‘Welcome Pack’ to suit individual service users’ needs. The Service users contract states that a trial period is four weeks is permitted for the benefit of the service user and the home. Evidence was seen in the care plans sampled that the pre-admission assessment had been gained to ensure the home could meet the individual service users’ needs. The home provides a detailed pre-admission assessment which assesses the service users ability in a number of key areas: domestic activity (housework/ cooking/ money & shopping), personal care, mobility, general physical health, sensory needs and communication, mental health, personal safety awareness (traffic, gas, fire), and finally learning/ leisure/ cultural and religious needs. The inspector saw supporting evidence that referrals are made to appropriate health care professionals for advice and guidance on caring for people with specific physical or mental health needs. The home also provides short-term stay as well as permanent residency. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The quality in this outcome group is good. Service users have a detailed care plan and appropriate risk assessments in place that have been agreed with them. Service users have right of access to health and medical services and the homes policies, procedures and practice strongly support this. The administration, storage and recording of medication are robust. Service users were supported to remain at the home if at all possible for the rest of their life. Their wishes and preferences are discussed sensitively with them and their family during the development of the care plan. EVIDENCE: The inspector examined four service users’ care plans. All the files contained detailed care plans that covered social, health and physical needs of the service users. The plans contained detailed instructions for staff on how to meet identified needs and are well organised, fully completed, dated and signed. There was evidence from checking the files and talking to staff and Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 11 service users that service users are involved in care planning and are asked to sign their agreement with the plans if they are able to do so. Care plans were reviewed monthly and any necessary changes noted and implemented by staff. All the files checked had up to date risk assessments in place in relation to the risk of falls, scalds and specific care needs such as diabetes and these had been reviewed and updated when service users’ needs had changed. Individual risk assessments were also in place in relation to using aids and adaptations. There were records of contact with GPs, district nurse and other healthcare professionals such as dentists, audiologist and chiropodist. There was good evidence on service users files checked that the home has good, effective relationships with other professionals and that referrals were made as appropriate for individuals. The inspector examined the Medication Administration Record (MAR) and storage of medicines. The storage was found to be clean, organised and well managed. The administration practice was of good standard. Some good practice guidance were recommended such as clearer variable dosage recording and labels on medication to state when it was opened and when to dispose by. The care plans clearly states service users wishes and preferences with regards to funeral planning. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome group is adequate. The routines of the home are planned around the service users’ needs and wishes. Service users are encouraged to personalise their rooms or flats. Appropriate activities are available throughout the home. More varied activities could be provided for the less mobile. Also, for those who prefer specific hobbies. Service users comments varied in that some service users were satisfied and some were not satisfied with the meals served in the home. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible. Service users choose to access activities provided by the home or engage in their own hobbies and pastimes. Service users are actively encouraged to keep in contact with family and friends living in the community. Visitors are made welcome at any time. Service users can choose to entertain visitors in their room, any one of the communal areas or in the garden. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 13 The routines of the home are planned around the service users’ needs and wishes. Personal choice is supported as much as possible. Service users are encouraged to personalise their rooms displaying their own keepsakes and photographs. Many have access to a private television and use of a personal telephone. Many service users are active and enjoy independent lives. Some service users choose to access the local community or go for walks independently. The activity room provides service users with a large space in which to fulfil a range of activities such as crafts, exercise bike, games such as chess and draughts (some of which are adapted for vision impairments), knitting, flower arrangements and music system. The activity file recorded the following activities carried out such as newspaper being read out to service users, quizzes, musical bingo, ‘Guess that tune’, reminiscence quiz, Guides visit, crossword, scrabble, crafts and flexicise. The frequency of key activities provided could be further improved. Some service users were out on a shopping trip to Burnham-on-Sea during the inspection. One service user spoken with felt that specific hobbies and personal interest were not so well catered for. The service user expressed interest in pursuing specific hobbies and often opted out of general activity. The provision of more detailed activity records specific to each service user would promote good practice. Service users are encouraged to be responsible for their own money for as long as they wish and/or supported by staff to maintain their independence as long as they are able. The homes policies and procedure guidance ensure that service users are protected from financial abuse. The inspector observed lunchtime routine and sampled the main meal of the day. Twenty-nine service users had their lunch in the dining room. Menus were seen to provide a varied and balanced diet. Mealtimes were seen to be unhurried, and support was available for service users requiring assistance. Staff were available to offer assistance discreetly if required. Deafblind manual finger spelling was used to inform a service user what was being provided and prompts. Staff were heard to ask service users before taking away their plates. Although staff were courteous, most staff did not engage sociably with the service users. The dining room tables were nicely laid with napkins and condiments available. The dark tablecloth contrasted with the white placemats to aid vision impairments. Comments from service users were gathered throughout the inspection process. These were through anonymous surveys as well as spoken accounts. These ranged from being satisfied to being dissatisfied with the quality of food provided. One service user informed the inspector that the quality of vegetables were poor that is tinned rather than freshly prepared. Also, that the meals were presented in such a way that the service user could not feel or Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 14 identify what it is. For example, mixed salad were cut up too small that a service user could not distinguish it apart. Another service user commented that the meals were not always suitable for diabetic. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The quality in this outcome group is good. Service users were confident that they could raise complaints or concerns with senior staff. Systems are in place to ensure that service users’ rights are respected. The home has policies and procedures in place to ensure the protection of service users living at Kathleen Chambers House. The homes’ complaints procedure complied with the national minimum standards and regulations. EVIDENCE: Staff spoken to were clear that they would pass on any concerns or complaints to the manager. Staff and service users confirmed that they would not hesitate to approach a senior member of staff or the manager should they have any concern. The manager provides monthly ‘surgery’ where the service user has an opportunity to chat and discuss their views in private. One service user spoken with confirmed this. Another service user spoken with experienced time delay in handling a complaint. The service user felt this was due to lack of clarity over which staff was responsible for addressing the matter. Service users also confirmed that there were regular residents meetings when any concerns could be raised. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 16 All service users are registered to vote and their legal rights protected by the homes values, policies and procedures. The Complaint procedure is displayed at the reception and included the Commission of Social Care Inspection and local Social Services contact details. This information is also provided in the service users’ contract and welcome pack. A complaint record is kept and the home had received three complaints since the last inspection. The inspector discussed the complaints with the assistant manager. These matters were minor and were dealt with appropriately. The Commission for Social Care Inspection (CSCI) has not received any complaint against the home. All staff, prior to employment at the home, had a POVAFirst check and Criminal Record Bureau (CRB) clearance. This ensures protection of vulnerable service users at the home. Four recruitment files viewed evidenced this. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome group is excellent. The home provides a well maintained, safe, comfortable home, which has all the specialist equipment and adaptations needed to meet individual service users needs. All service users are assessed for their need to have equipment or aids before they move into the home and as necessary thereafter. The additional communal space provides service users choice and scope to meet relatives and friends in privacy and comfort. Service users are encouraged to personalise their rooms with their own belongings. EVIDENCE: The home was very clean, tidy and odour free on the day of the inspection. The furnishings, decoration and fittings of a high standard and service users are able to bring in items of their own furniture by agreement with the home and to personalise their rooms in line with their choices and preferences. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 18 There is a selection of communal areas, according to the numbers of service users, this means that service users and their visitors have a choice of place to sit quietly, and meet with family and friends. The home has seating available in the gardens and these are very well maintained and fully accessible for those service users with mobility problems or who use wheelchairs. The bathrooms are clean and tidy. Baths or showers are provided with appropriate aids and adaptations in order to meet service users needs. There are a number of toilets strategically placed around the home. Call bells are left within reach of service users and these are responded to promptly. Good laundry facilities are provided and service users spoken to confirmed that their clothes were always well laundered and returned to them promptly in good condition. The kitchen was inspected and found to be reasonable. The larder were well stocked with long life food. The paperwork sampled showed that some details has not been kept up to date. Some fresh fruits and vegetables were seen stored on the floor in the cleaners’ store. This would be more appropriately stored off the ground. Fridge and freezer temperatures were recorded regularly. Cleaning schedules were up to date and maintained for the month of August. There is textured flooring throughout the home to indicate different areas and a ‘talking notice board’ that tells service users the activities for the day and the senior staff on duty. The home provides hairdressing salon, spa bath, library, training room (for staff) and a well equipped activity room. Each bedroom has its own small kitchenette and also has en-suite facilities. There is a well maintained level garden that has rails all round so that service users can use it independently. The garden comprises a range of outdoor stimulation such as a raised flowerbed, vegetable plot, trellis walkway with garden benches, memorial garden, herb garden and colourful 1930’s boat on display. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 The quality in this outcome group is good. Staffing levels are good and the staff were well qualified. Service users have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. EVIDENCE: On the morning of the inspection, there was; one acting manager, one assistant manager, one supervisor, three care staff, one cook, one catering assistant, one activity co-ordinator, one receptionist, one maintenance, one gardener, one laundry staff, and three housekeeping staff. During the afternoon, there were; one supervisor, three care staff and two catering staff. There are currently twenty-one care staff and twenty-eight ancillary staff, twelve of which are qualified to NVQ 2 and above therefore the staff team have the skills and experience to provide a high standard of care. Four staff files were checked. These files contained two written references and evidence of proof of identity. The files were generally well kept. Some supervision were seen to be out of date. The home provided information on the pre inspection questionnaire about the training that staff had been doing recently and this included mandatory training, disability awareness, infection control, sensory loss, medication, and Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 20 care practice. Staff spoken to confirmed that they were supported and encouraged by Mrs Main-Reade to attend training to obtain skills and qualifications relevant to their role. The inspector discussed with the manager the quality of Adult Protection training provided. The manager agreed that more detailed training could be provided in this area. Care staff spoken with confirmed that the manager operated an ‘open door’ policy that is they felt able to approach her with any queries. Catering staff informed the inspector that there is not enough catering staff in place. The management is attempting to address this with consultation period and support from housekeeping staff. However, it was apparent that this was affecting catering staff morale, which consequently affects the usually high standard of cleanliness in the kitchen and quality of food provided. Care staff stated that they have received induction, appraisals and formal one to one supervision. It is recommended that formal 1:1 supervision are provided at least six times a year as outlined in the National Minimum Standards. Service users spoken to were very complimentary about staff and they were described as ‘I think they are wonderful’ and ‘They are very kind’. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 The quality in this outcome group is good. The manager has the required qualifications, skills and experience and is competent to run the home. Service users and staff are kept informed and involved in the running of the home. Service users are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. EVIDENCE: The acting manager is Mrs Margaret Main-Reade and assistant manager Mrs Stephanie Cahill supports her. Margaret has many years experience as Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 22 assistant manager and has applied to the Commission for Social Care Inspection (CSCI) to be registered. Margaret has completed a Postgraduate Certificate in Management and will work towards NVQ level 4. Service users spoken with confirmed that they felt able to approach the manager and assistant manager if they wished to raise issues. The home currently does not directly handle the service users financial affair. Twenty-one service users have power of attorney in place. Financial records are kept relating to service users fees. Staff spoken with confirmed that they felt well supported and able approach the manager should they wished to discuss day to day running of the home. Service users confirmed that the manager offers a monthly ‘surgery’ for those who wish to speak with the manager in private. Staff also confirmed that staff meeting take place and that formal supervision are provided. However, it is recommended that the home provide all staff with formal supervision at least six times a year as outlined in the National Minimum Standards. A tour of the premises was made and areas seen were free from hazards. The inspector discussed with the manager about introducing Braille information to signpost fire and danger signs throughout the home. The home has excellent Braille signs to help identify rooms and its function. Information were provided that confirmed the following; fire test, gas servicing, lift engineer, hoist, call bell and electrical equipment were subject to regular checks and had been serviced. The home contracts an external agency to test and check the water system as preventative strategy against Legionella. The accident book was checked and there were low level of incidents. These related to slips and falls and appropriate action were made and care plan updated. Risk assessments were seen in place and up to date in care plans. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 4 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 3 3 4 4 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 3 Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations It is recommended that two staff signatures support all hand transcribed entries on Medication Administration Record. It is recommended that variable dosage recording be used to indicate actual quantity given. Also, labels on all medication to indicate when it was opened and when to dispose by. It is recommended that formal 1:1 staff supervision are provided at least six times a year as outlined in National Minimum Standards. It is recommended that the manager consider recording in each service users’ care plan, individual and group activities attended by each service user. It is recommended that the manager consider providing further Braille information in order to fully access fire alarm points and danger signs on cupboards. DS0000031544.V305468.R02.S.doc Version 5.2 Page 25 3. 4. OP36 OP12 5. OP38 Kathleen Chambers House 6. OP27 It is recommended that the manager provide the Commission with plan and agreed outcome detailing how catering staff will be employed to ensure that standards relating to food, meals and nutrition are fully met. Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kathleen Chambers House DS0000031544.V305468.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!